The IEO is the leading center for all those key achievements in the field of breast surgery which were introduced and validated at the IEO and now adopted all over the world. Our Institute treats the largest number of breast patients in the world with more than 3,600 surgical operations per year. Attending a Centre of Excellence such as the IEO for prevention, early and accurate diagnosis of breast cancer and its biological characteristics and treatments, maximises the probability of complete cure.

STAFF

At the IEO breast cancer is treated by a multidisciplinary team consisting of specialists in:

• Breast Cancer Surgery
• Breast Cancer Medical Treatments
• Plastic and Reconstructive Surgery
• New Drugs and Early Drug Development for Innovative Therapies
• Department of Pathology and Laboratory Medicine
• Department of Medical Imaging and Radiation Sciences

The first step to a proper prevention programme is to assess the risk profile and the probability that a person has of developing breast cancer. It has now been demonstrated that the risk of developing the breast cancer is different for every woman and this can be evaluated by a thorough assessment of personal, family, and biological characteristics.

Assessment of individual breast cancer risk

It is no longer sufficient to talk about "risk" referred to the general population but it is instead appropriate to make an assessment of an "individual risk" and to do this requires a thorough collection and analysis of the (1) personal, (2) family, and (3) biological characteristics of each person.

1. Individual characteristics: age, medical history, age at first menstruation and menopause, pregnancy, breastfeeding, previous or current hormone therapies, physical characteristics (height, weight, body mass index, overweight and obesity, any presence of metabolic syndrome), lifestyle (diet, physical activity, smoking, alcohol).
2. Family characteristics:the presence or absence of cancer in the family (especially the presence of breast and/or ovarian cancers in 1st and 2nd degree relatives). There is the possibility - by completing (in appropriate cases) a family questionnaire and by building a family tree - to calculate the risk within a family and begin a process of "genetic counselling" which can in some cases lead to a genetic test for the detection of mutations (e. g. BRCA 1-2), or a series of diagnostic and therapeutic advice to be taken in the event of a high probability of mutation.
3. Biological characteristics: such as the presence of atypical cells or other types of precancerous lesions, potentially found in previous tests (biopsies, needle-aspirated and/or interventions) or through recently introduced instrument-based screening techniques such as DUCTAL LAVAGE and/or HALO BREAST TEST of breast fluids. (1)

Analysis of this information makes it possible to highlight the individual risk profile of each patient and accordingly set up a PERSONALISED PROGRAMME FOR CLINICAL AND INSTRUMENTAL MONITORING, with particular attention paid to the choice of the tests, frequency, and the age at which you start to take them. In selected cases, assessment of the individual risk can lead to recommendation for a course of drugs as a preventive measure or participation in a clinical trial of drug-prevention. (2)

Risk factors for breast cancer

Being predisposed to the development of breast cancer is associated with several factors:

• genetic factors are relatively rare, but of particular interest
• epidemiological factors of relative importance: family history, early age menstruation and late age menopause, no pregnancy or first pregnancy after the age of thirty, little or no breastfeeding, obesity and alcohol consumption.

Despite their importance, these risk factors are not sufficient to explain all cases of breast cancer. Seventy per cent of breast cancer cases occur in women presenting no known risk factors, which is why it is right and appropriate that all women are informed about prevention, thereby deciding to adopt it with the help of specialist centres. Based on current knowledge, risk factors do not necessarily have an impact on the rate and type of early diagnosis, except in cases of genetic mutation. Prevention can save the lives of all women, regardless of risk factors.

Prevention and the appropriate treatments have been shown to reduce the damage that breast cancer can cause. Thanks to prevention, care and a greater degree of breast cancer awareness, the survival rate is clearly progressively increasing.

The expertise in the different areas of Radiology, Surgery, Medical Oncology, Radiotherapy, Chemoprevention, Nuclear Medicine and other specialties involved in the management of breast cancer patients work together in order to define the best approach for every single case. Personalised diagnosis, treatment and follow up is the strategy that allows us to achieve optimal results in terms of cure, breast cancer control, quality of life.

That's why the IEO Breast Program, which brings together all those Divisions and Units involved in the prevention, prognosis, diagnosis and treatment of breast cancer was created. Breast cancer treatment is multidisciplinary. It is not enough to refer to surgery, radiotherapy or pharmacotherapy alone, without integrating the various disciplines.

The most common breast cancer symptoms

One should never wait for breast cancer symptoms to appear. Early diagnosis means identifying problems before they appear as symptoms or signs. Medical attention should be sought when one can see or feel:

• one or more nodules of the breast – by nodule we mean a circular hardening, a part that is differently textured from the rest of the breast, or a real lump, whether mobile or fixed.
• swelling or thickening of the breast or underarm area
• changes in the shape or size of the breast
• secretion of fluid from the nipple - the liquid can come out spontaneously (spots on the bra or clothing) or when the nipple is squeezed or touched, and may have different colours (white, transparent, yellow, green, bright red, dark red)
• changes in appearance of the skin, nipple or areola, such as dimples or retraction, swelling, redness, heat, cracking.

Breast pain is not usually a symptom of breast cancer. However, it is always wise to report it to your referring physicianfor your reassurance.

Breast cancer awareness: the importance of prevention

At the IEO, the primary prevention of breast cancer is promoted by integrating different approaches. A specific area of oncology is dedicated to prevention by studying and applying new strategies aimed at identifying individuals or family groups at high risk (genetic, familial, metabolic), people with precancerous lesions and patients of IEO at high risk of developing a second cancer. Personalised check-ups and close supervision of those who are at high risk forms part of the clinical activities of this specific area.

Primary prevention can prevent the onset and development of a breast cancer. Primary prevention takes the form of adopting a behaviour (or taking a substance) that can reduce the risk of getting a disease. Breast cancer primary prevention is based on lifestyle and - still at the experimental stage - on taking certain substances in very high risk cases documented by positive genetic test. A correct lifestyle involves constant and regular exercise at least three times every week (60 minutes per session), abstaining from smoking and alcohol consumption and proper nutrition.

Secondary prevention is early detection. Discovering a breast cancer while still at an early stage, small and still non-palpable, means a high probability of complete cure with surgical and pharmacological treatments of minimal intensity and minor discomfort. However, if diagnosis is later there are still effective treatments available. An initial stage of breast cancer has a higher chance of a full and complete recovery, but even those with a more advanced breast cancer have a good chance of controlling the disease in the long term with care and adequate follow up.

DIAGNOSIS OF BREAST CANCER

Diagnosis of breast cancer is based on diagnostic tests and clinical breast examination. Whether it is prevention (early detection) or follow-up visits after treatments already received for breast cancer, these procedures are fundamental for all women. It is important to regularly undergo breast examinations before symptoms of breast cancer appear.

Mammography

Mammography, i.e. an X-ray of the breast, is useful for detecting the presence of nodules, microcalcifications or other indirect signs of breast cancer. It is based on X-rays that imprint the image onto a plate (or computer) after passing through the breast. The X-ray dose you receive during mammography is not harmful to your health. It is performed from the age of 40, every year or every two years.

Ultrasound

Ultrasound makes use of high-frequency sounds to detect the presence of a nodule and its consistency, solid or liquid, defining whether it is benign, doubtful or malignant in nature. Ultrasound is completely harmless from a biological point of view and is carried out every year from the age of 30; it is stopped when the radiologist recommends it.

Breast MRI

Breast Magnetic Resonance Imaging (MRI) makes use of a magnetic field to create the image of the tissue with mammography and ultrasound, or when prostheses or images near a surgical scar are to be displayed in detail. It is indicated when necessary or is planned as part of early diagnosis in women who have a high breast cancer risk due to family history or when the mammary structure appears complex using the other image investigations.

Fine-needle biopsy

Fine needle biopsy is a test during which a sample of cells from a breast nodule is taken using a thin needle and a cytological examination is thus obtained.

Needle-biopsy

Needle biopsy is a technique that takes a sample of tissue from an area or from a suspected nodule in order to obtain a histological examination accompanied by all the biological characteristics of the malignant tissue.

Self-examination

Self-examination is not a tool for early diagnosis and not enough to keep your health under control. The optimum early diagnosis is achieved when breast cancer is discovered when not yet palpable (with diagnostic tests).

Genetic test

The genetic test is a blood test that allows an assessment of whether there is a mutation in one of two genes known to be the most frequent in highly increasing the risk of breast cancer and/or ovarian cancer: the genes are called BRCA1 and BRCA2. Patients receive genetic counselling in which they may discuss the consequences of a positive, negative or uncertain result of the test.

Clinical breast examination

The clinical breast examination completes the diagnostic testing and concludes the process in view of further and future controls (healthy breast) or the necessary care (presence of breast cancer or suspected lesions). During the examination, test results are checked, the breast, underarm and supra clavicle lymph nodes are palpated, and treatment is prescribed, should it be useful to resolve doubt or certainty of breast cancer.

Preventive bilateral mastectomy is not seen as a tool of standard prevention; the basis for effective prevention is personalisation. Depending on the rapport between the patient and the referring physicians, it may be possible to take the decision to remove both breasts in very high breast cancer risk cases (positive genetic test) and in cases of particular requirements discussed with the person. The clinical breast examination is performed at the outpatient clinic of the Breast Division or at the outpatient office of one of IEO breast specialists.

Breast cancer preventive nutrition

Thanks to the SmartFood project, healthy-eating based on scientific findings is explained and disseminated via events, publications, courses, and personalised advice. Ten recommendations for women's health were presented at the IEO women’s health event.

Type of breast cancer

Breast cancer can begin in different areas of the breast — the ducts, the lobules, or in some cases, the tissue in between.

There are different types of breast cancer, including non-invasive, invasive, and metastatic breast cancers, as well as the intrinsic or molecular subtypes of breast cancer.

• Ductal Carcinoma In Situ (DCIS)
• Invasive Ductal Carcinoma (IDC)
• IDC Type: Tubular Carcinoma of the Breast
• IDC Type: Medullary Carcinoma of the Breast
• IDC Type: Mucinous Carcinoma of the Breast
• IDC Type: Papillary Carcinoma of the Breast
• IDC Type: Cribriform Carcinoma of the Breast
• Invasive Lobular Carcinoma (ILC)
• Inflammatory Breast Cancer (IBC)
• Lobular Carcinoma In Situ (LCIS)
• Male Breast Cancer
• Molecular Subtypes of Breast Cancer
• Paget's Disease of the Nipple
• Phyllodes Tumors of the Breast
• Metastatic Breast Cancer

Ductal Carcinoma In Situ (DCIS)

Ductal carcinoma in situ (DCIS) is non-invasive breast cancer because it hasn’t spread beyond the milk duct into any normal surrounding breast tissue.

Invasive Ductal Carcinoma (IDC)

Invasive ductal carcinoma (IDC), sometimes called infiltrating ductal carcinoma, is the most common type of breast cancer. About 80% of all breast cancers are invasive ductal carcinomas. “Invasive ductal carcinoma” refers to cancer that invades the tissues of the breast. Over time, invasive ductal carcinoma can spread to the lymph nodes and possibly to other areas of the body.

IDC Type: Tubular Carcinoma of the Breast

Tubular carcinoma of the breast is a subtype of invasive ductal carcinoma. Tubular carcinomas are usually small (about 1 cm or less), they tend to be low-grade, meaning that their cells look somewhat similar to normal, healthy cells and tend to grow slowly.

IDC Type: Medullary Carcinoma of the Breast

Medullary carcinoma of the breast is a rare subtype of invasive ductal carcinoma. Medullary carcinoma doesn’t grow quickly and usually doesn’t spread outside the breast to the lymph nodes.

IDC Type: Mucinous Carcinoma of the Breast

Mucinous carcinoma of the breast is a rare form of invasive ductal carcinoma. In this type of cancer, the tumor is made up of abnormal cells that “float” in pools of mucin, a key ingredient in the slimy, slippery substance known as mucus. Even though mucinous carcinoma is an invasive breast cancer, it tends to be a less aggressive type that responds well to treatment.

IDC Type: Papillary Carcinoma of the Breast

Invasive papillary carcinomas of the breast are rare, accounting for less than 1-2% of invasive breast cancers. In most cases, these types of tumors are diagnosed in older women who have already been through menopause.

IDC Type: Cribriform Carcinoma of the Breast

In invasive cribriform carcinoma, the cancer cells invade the stroma (connective tissues of the breast) in nestlike formations between the ducts and lobules. Invasive cribriform carcinoma is usually low grade, meaning that its cells look and behave somewhat like normal, healthy breast cells.

Invasive Lobular Carcinoma (ILC)

Invasive lobular carcinoma (ILC), sometimes called infiltrating lobular carcinoma, is the second most common type of breast cancer after invasive ductal carcinoma. Although invasive lobular carcinoma can affect women at any age, it is more common as women grow older.

Inflammatory Breast Cancer

Inflammatory breast cancer (IBC) is a rare and aggressive form of breast cancer. Inflammatory breast cancer usually starts with the reddening and swelling of the breast instead of a distinct lump. IBC tends to grow and spread quickly, with breast symptoms as worsening within days or even hours.

Lobular Carcinoma In Situ (LCIS)

Lobular carcinoma in situ (LCIS) is an area (or areas) of abnormal cell growth that increases a person’s risk of developing invasive breast cancer later on in life. LCIS is not a true breast cancer. Rather, LCIS is an indication that a person is at higher-than-average risk for getting breast cancer at some point in the future.

Male Breast Cancer

Breast cancer in men is a rare disease. Less than 1% of all breast cancers occur in men. For men, the lifetime risk of being diagnosed with breast cancer is about 1 in 1,000.

Molecular Subtypes of Breast Cancer

There are five main intrinsic or molecular subtypes of breast cancer that are based on the genes a cancer expresses:

• Luminal A :breast cancer is hormone-receptor positive (estrogen-receptor and/or progesterone-receptor positive), HER2 negative, and has low levels of the protein Ki-67, which helps control how fast cancer cells grow.
• Luminal B breast cancer is hormone-receptor positive (estrogen-receptor and/or progesterone-receptor positive), and either HER2 positive or HER2 negative with high levels of Ki-67.
• Triple-negative breast cancer is hormone-receptor negative (estrogen-receptor and progesterone-receptor negative) and HER2 negative. This triple-negative breast cancer is more common in women with BRCA1 gene mutations. Researchers are unsure why, but this type of triple-negative breast cancer also is more common among younger women. Using chemotherapy to treat triple-negative breast cancer is still an effective option. In fact, triple-negative breast cancer may respond even better to chemotherapy in the earlier stages than many other forms of breast cancer.
• HER2-enriched breast cancer is hormone-receptor negative (estrogen-receptor and progesterone-receptor negative) and HER2 positive
• Normal-like hormone-receptor positive (estrogen-receptor and/or progesterone-receptor positive), HER2 negative, and has low levels of the protein Ki-67.

Paget's Disease of the Nipple

Paget's disease of the nipple is a rare form of breast cancer in which cancer cells collect in or around the nipple. The cancer usually affects the ducts of the nipple first (small milk-carrying tubes), then spreads to the nipple surface and the areola (the dark circle of skin around the nipple).

Phyllodes Breast Cancer

Phyllodes tumors of the breast are rare, accounting for less than 1% of all breast tumors. Phyllodes tumors can occur at any age , the tumor cells grow in a leaflike pattern.and they tend to develop when a woman is in her 40s.

Metastasized Breast Cancer

Metastasized breast cancer is breast cancer that has spread to other parts of the body. The metastasized breast cancer (also called stage IV or advanced breast cancer) is not a specific type of breast cancer, but rather the most advanced stage of breast cancer. Metastasized breast cancer is breast cancer that has spread beyond the breast to other organs in the body (most often the bones, lungs, liver or brain).Although metastasized breast cancer has spread to another part of the body, it is considered and treated as breast cancer.

Personalized care for breast cancer treatment: excellence at the IEO

The treatment of breast cancer is based on surgery associated with radiation therapy and pharmacological treatment, according to the specific situation. An element of excellence that characterises the IEO Breast Programis exact biological knowledge of each individual breast cancer before starting treatment. Breast medicine is a discipline that combines different skills, expertise and specialisations that together determine every therapeutic decision and study or control for each patient affected by breast cancer.

A crucial moment in the personalisation of care is the multidisciplinary discussion among the members of the Programme: each single case is discussed in accordance with the spefgic biological characteristics of breast cancer, physical characteristics and personal and family medical history and with distinguishing psychological needs and expectations.

The discussion occurs after surgery in the majority of cases, or before each type of therapeutic approach if the breast cancer has a diameter or local extension that requires a decision to be made between primary surgery or secondary surgery following drug treatment: for this, every time breast cancer is considered to be locally extended (for example if the diameter exceeds 2 cm), we proceed to the next microbiopsy with group discussion to determine the orientation toward surgery or neoadjuvant drug therapy.

Knowing the biology of breast cancer is crucial so that every patient is given indications with the highest probability of efficacy on breast cancer with the least detriment to their quality of life.

IEO breast surgery leads the world in terms of operations performed each year. Seventy per cent of the cases performed are quadrantectomy, or partial resection, i.e. removal of the breast cancer with a certain amount of the surrounding healthy tissue. In 30% of cases, mastectomy must be performed, which is removal of the entire breast followed by immediate reconstruction via plastic-reconstructive surgery techniques.

ROLL

When the breast cancer is not palpable (micro calcifications or very small nodules), localisation techniques are used to avoid errors and unnecessary removal of healthy tissue: ROLL (Radioguided Occult Lesion Localisation), a technique devised at the IEO, is the most widely-used technique around the world with the best results, but it is possible to opt for preoperative skin marking of the part to be operated on.

Radiotherapy and mastectomy for breast cancer

When mastectomy is required, in the majority of cases IEO can provide immediate reconstruction using techniques that depend on the individual situation: cooperation between breast experts and plastic-reconstructive surgeons allows us to achieve the best aesthetic result following surgery for removing breast cancer. Breast-conserving surgery and, more rarely, mastectomy may be followed by radiation therapy.

Radiotherapy

Radiotherapy following breast cancer surgery is a normal procedure in quadrantectomy or partial resection. It is defined as "complementary" because it completes breast-conserving surgery and reduces the risk of breast cancer recurrence. It can be prescribed after surgery in some special situations when it is necessary to treat the chest wall and / or lymph nodes. The use of radiation therapy is expected in metastatic breast cancer in locations responding well to treatment with ionising radiation (such as bones).

Intraoperative Radiotherapy

Intraoperative radiation therapy forms one of the symbols of excellence in breast cancer care at IEO. Thanks to studies carried out at IEO, it can be performed in the course of a quadrantectomy intervention as a single dose of 21 Gy that completely replaces the course of external beam radiation therapy or at a dose of 12 Gy as an early boost followed by a shorter course of external beam radiation therapy. Intraoperative radiotherapy is used in some cases of nipple-sparing mastectomy for irradiating the nipple-areolar complex kept in place.

Nipple-sparing mastecomy

"Nipple-sparing" mastectomy is a surgical technique that was developed by our institute more than 10 years ago (first interventions dating back to 2002). This action allows the removal of the mammary gland while preserving the outer shell (skin and nipple) entirely with optimal preservation of feminine appearance. Breast reconstruction is performed simultaneously with the mastectomy, usually with implants (expander or definitive prosthesis). Over the years, the technique has constantly improved. The tissue behind the areola is completely and radically removed and thanks to the refinements of surgical technique, the risk of complications, nipple necrosis in particular, is very low and constantly reducing. In order to maximise breast cancer eradication, an intraoperative histological examination is always performed of the tissue immediately below the nipple. In cases of histologically positive neoplasia or carcinoma in situ, the nipple-areolar complex must be removed. Should additional elements emerge from the definitive histological examination, the need for postoperative irradiation limited to the nipple-areolar complex or extended to the entire breast area and/or lymph node region is assessed through multidisciplinary consulting.

Pharmacological treatments for breast cancer

The pharmacological treatments, i.e. chemotherapy and/or endocrine therapy and/or the so-called receptor medications, depend on the histological examination related to breast cancer surgery.

Chemotherapy

Chemotherapy consists of drugs and regimens that vary according to the person and breast cancer characteristics and it is prescribed as a precautionary measure when risk factors suggest a higher coverage or in cases of breast cancer that is not sensitive to the hormones oestrogen and progesterone. Chemotherapy may be prescribed together with endocrine therapy or receptor medications but not in all cases.

Endocrine theraphy

Endocrine therapy is based on drugs that reduce the activity of oestrogen hormones and progesterone. It is prescribed when the breast cancer is sensitive to these hormones and must therefore be blocked for a certain period of time. There are different drugs and their prescription depends on the individual situation.

Receptor medication

The receptor drugs are very specific and their effectiveness is linked to some details of the histology exam evaluated by the oncologists.

WOMEN’S CANCER CENTER

IEO Women's Cancer Center (WCC) is the first centre in Italy dedicated to the world of female tumours as a whole: from the management of the risk of getting sick, to early diagnosis, to treatment, all the way to the reintegration into everyday life with the return to an individual’s life routine. It is therefore "a place for women", dedicated to women's health as a whole, for women who are involved in prevention and for those who, in contrast, are experiencing or have experienced illness. The IEO Women's Cancer Center provides each woman with her own personalised course of prevention as a result of preventive strategies that have been collectively decided and collectively applied. Every woman can access a preventive programme that is appropriate for her age and risk profile created by the teamwork of IEO specialists, and with the highest level of professional expertise.

For more information please send an email to : [email protected]

The IEO plays a key role in Breast Cancer Awareness Month, symbolized by a pink breast cancer ribbon. This is an annual health campaign held every October organized by major breast cancer charities to increase awareness of the disease and to raise funds for research into its cause, prevention, diagnosis, treatment and cure.

Regarding the Breast Cancer Awarness Month IEO organizes futher events as Bra Day and others in collaboration with ONDA.